Report of the Inquiry into the circumstances of the Death of Bernard ...

or recognition. Their actions may be subject to microscopic scrutiny when something
goes wrong. Less attention is paid to acts of kindness and it is too little recognised that
they save many lives. Prison staff are individuals, with feelings, just as prisoners and
their families are.
The report
2.34 This report was sent in draft to the interested parties and to Counsel for the
prison officer witnesses. The draft or extracts from it were provided to 31 people
identified in the report. In accordance with the Inquiry Rules 2006, I sent ‘warning letters’
in confidence to people who had not already been made aware that their actions might
be criticised. In completing this final report I have taken account of all the replies I
received.
The legal advisers
2.35 I am deeply grateful to Mr Chris Topping, the solicitor to the inquiry for his untiring
and wise counsel to me throughout the process. I also thank the legal representatives of
witnesses and the interested parties who approached the inquiry in a non-adversarial
and unfailingly courteous manner and were patient and constructive in their submissions.
Lessons about inquiry procedure
2.36 With the benefit of hindsight, I have considered carefully whether it would have
been preferable for the investigation to have been on a statutory footing from the start.
Ad hoc investigations established on a non-statutory footing have some advantages.
They can be set up swiftly. Terms of reference can be easily revised if circumstances
require it. Statutory inquiries have the advantage that all those asked to provide
evidence know that they are required to do so.
2.37 From my experience in this inquiry, the only disability from the lack of statutory
powers was that one reluctant witness could not be compelled to attend. That was
remedied when the inquiry was converted. In all other respects I received full
cooperation from everyone from whom I sought access to evidence, statements and oral
testimony. I consulted the parties throughout the process but, once I had heard the
arguments, all the decisions were my own. There has been no constraint on my
independence. I have concluded that the reluctance of one witness in the particular
circumstances of this case is not good reason to recommend a presumption that Article
2 investigations should generally be statutory inquiries. However, inconvenience, delay
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